Controlling Onchocerciasis (River Blindness) in Sub-Saharan Africa

Case 7 Controlling Onchocerciasis (River Blindness) in Sub-Saharan Africa

Geographic area: Sub-Saharan Africa

Health condition: In 11 west African countries in 1974, nearly 2 million of the area’s 20 million inhabitants were infected with onchocerciasis, and approximately 200,000 were blind.

Global importance of the health condition: Onchocerciasis, or river blindness, afflicts approximately 42 million people worldwide, with well over 99 percent of its victims in sub-Saharan Africa. An estimated 600,000 people are blind, and an additional 1.5 million Africans are visually impaired due to onchocerciasis.

Intervention or program: The Onchocerciasis Control Program (OCP) was launched in 1974 in 11 west African countries. Weekly aerial spraying with environmentally safe insecticides helped control the disease vector—blackflies that bred in fast-moving waterways, thereby halting transmission of the disease. In 1995, a second program, the African Programme for Onchocerciasis Control (APOC), was established to control the disease in 19 central, east, and southern African countries. Through a broad international partnership and the participation of 115,000 remote, rural communities, APOC and OCP distributed a drug donated by Merck & Co., Inc., Mectizan (ivermectin), to more than 45 million people in sub-Saharan Africa in 2005. The drug prevents and alleviates the symptoms of the disease with one annual dose.

Cost-effectiveness: OCP operated with an annual cost of less than $1 per protected person. Commit- ments from 27 donors during the 28-year project totaled $600 million. The annual return on investment was calculated to be about 20 percent, primarily attributable to increased agricultural output; about $3.7 billion will be generated from improved labor and agricultural productivity. The annual cost of APOC operations, taking into account the donation of all needed drugs, is approximately $0.58 per person treated.

Impact: OCP produced an impressive change in health between 1974 and 2002: Transmission of the disease-causing parasite was halted in 11 west African countries, 600,000 cases of blindness were prevented, and 22 million children born in the OCP area are now free from the risk of contracting river blindness. About 25 million hectares of arable land—enough to feed an additional 17 million people per annum—is now safe for resettlement. APOC is expanding this success to central, east, and southern Africa, where 54,000 cases of blindness are expected to be prevented each year.

t the headquarters of the World Bank, the as in a prominent square in Ouagadougou, Burkina WHO, the Carter Center, the multinational Faso, visitors see a distinctive statue of a child lead- pharmaceutical firm Merck, and the Royal ing a blind man—a symbolic reminder to passersby ATropical Institute of the Netherlands, as well of the part each partner played in the control of one of Africa’s most devastating diseases. The Onchocer- The first draft of this case was prepared by Jane Seymour and Molly ciasis Control Program (OCP) has earned its place Kinder; significant contributions to the current version were made by Bruce Benton. as one of the signal achievements of international

Controlling Onchocerciasis (River Blindness) in Sub-Saharan Africa public health, demonstrating the power of collabora- productivity and spend a large portion of their income tion across countries and agencies, the importance of on extra health costs.3 long-term funding from the donor community, and the benefits of public-private partnership to bring On a community level, the disease has hindered eco- pharmaceutical innovation into large-scale use in nomic growth. The threat of the disease has led people developing countries. to abandon more than 250,000 square kilometers of some of the best arable land in west Africa. In the words The Disease of Dr. Ebrahim Samba, OCP’s director from 1980 to 1994, “Onchocerciasis therefore is a disease of human Onchocerciasis, or “river blindness,” is a pernicious beings and also of the land. It directly retards develop- disease that afflicts approximately 42 million people ment and aggravates poverty.” worldwide, with well over 99 percent of its victims resid- ing in sub-Saharan Africa. Primarily a rural disease, on- Combating the Disease: The chocerciasis disproportionately burdens the inhabitants Onchocerciasis Control Program of some of the poorest and most remote areas in Africa. Small, isolated areas in Latin America and Yemen also Colonial and ex-colonial entomologists attempted for are affected. In the most endemic areas, more than one many years to control the disease in the hardest-hit third of the adult population is blind, and infection areas, but achieved mixed results. Lasting results proved often approaches 90 percent of the population.1 elusive because the blackflies cover long distances (exceeding 400 kilometers with the wind currents) and The disease is caused by a worm, Onchocerca volvulus, cross national boundaries, rendering uncoordinated which enters its human victim through the bite of an national control efforts ineffective. infected blackfly. In the arable riverine areas where the flies breed, residents are bitten as many as 10,000 times The small-scale control efforts of the 1950s and 1960s a day. Once inside a human, the tiny worm grows to provided the seeds for the first regional OCP, which two to three feet in length, each year producing millions were codified at an international conference in Tunisia of microscopic offspring called microfilaria. These tiny in 1968.4 The disease, concluded conference partici- worms are so abundant that a simple snip of the skin pants, would be controlled if it could be addressed on a can expose hundreds of writhing worms. sufficiently large scale. Scientists from WHO and other experts contributed to the preparation of a regional The constant movement of the microfilarie through the control plan. Several donors expressed mild interest, but infected person’s skin causes a wide range of debilitating none was able to commit alone what was expected to be symptoms, including disabling and torturous itching, a 20-year, $120 million program covering at least seven skin lesions, rashes, muscle pain, weakness, and, in countries. its most severe cases, blindness. The disease is spread when a new blackfly bites an infected person and then Serendipity intervened. In 1972, the then-president of bites another person, thus repeating the infection cycle. the World Bank, Robert McNamara, visited west Africa Today, an estimated 600,000 people are blind due to on- to observe the impact of a long drought that was under- chocerciasis, and nearly 1.5 million are severely visually way. While visiting the rural areas of Upper Volta (now impaired.2 Burkina Faso), he witnessed the devastation caused by onchocerciasis; he saw many children leading blind Beyond the disabling health burden, onchocerciasis adults, and communities in which nearly all the adults inflicts tremendous social and economic damage on were blind. McNamara decided to spearhead an interna- individuals and entire communities. Self-esteem and tional effort to control the disease, committing his own concentration suffer, and the disease reduces marriage institution to a catalytic financing role.1 prospects for both women and men. Infected individuals often earn less money as a result of decreased The OCP was launched in 1974 under the leadership of the WHO, the World Bank, the Food and Agriculture

2 Controlling Onchocerciasis (River Blindness) in Sub-Saharan Africa Organization (FAO), and the United Nations Develop- 100,000 were blind. Today, transmission of the disease ment Program (UNDP). Financing and donor support has been virtually halted, and some 1.5 million people were mobilized through the World Bank from a wide who once were infected with the disease no longer range of donor countries, multilateral institutions, and experience any symptoms. An estimated 600,000 cases private foundations. of blindness have been prevented, and 22 million children born in the area since the program’s inception are The program, the first large-scale health program ever free from the risk of river blindness. supported by the World Bank, set out to eliminate the disease first in 7—and eventually in 11—west African The economic impact has also been impressive. An es- countries. The primary intervention was vector control timated 25 million hectares of unusable arable land— of the disease-spreading blackflies, with the goal of enough to feed an additional 17 million people per ultimately halting disease transmission. Helicopters annum—has become available for agricultural produc- facilitated the weekly spraying of larvicides during rainy tion and resettlement.5 In Burkina Faso, for example, seasons on the riverine areas most heavily populated by 15 percent of the country’s land that had been deserted blackflies. The aerial treatment, as well as hand spraying because of the disease has been completely reclaimed, of breeding grounds, persisted even through civil and and its new residents now enjoy a thriving agricultural regional conflicts and coups. economy.6

Up-to-date information was a key element in pro- The program, which formally concluded in December gram implementation. Detailed mapping of the 12,000 2002, was extremely cost-effective and had a yearly miles of remote rivers and epidemiological mapping cost of less than $1 per person protected. Total com- of onchocerciasis prevalence facilitated these efforts. A mitments from 27 donors during the 28-year project significant operational research budget was built into amounted to $600 million. The World Bank calculated the program to respond to emerging challenges and the annual return on investment (attributable mainly problems and to investigate effective prevention and to increased agricultural output) to be 20 percent, and treatment options. it is estimated that $3.7 billion will be generated from improved labor and agricultural productivity.4 The duration of the program and its phasing were spe- cial features. Because of the time needed for the adult A Medical Breakthrough: Mectizan Is worms in the human population to die off, which at the Discovered time was thought to be at least 18 years, the program was expected to last 20 years. The administrative and While OCP was proving its success in controlling on- financial agreements were broken into 6-year phases, chocerciasis in the 11 designated west African countries allowing for both firm commitment and flexibility in during the 1970s and 1980s, the disease remained en- planning cycles. Most of the original nine donors sup- demic in 19 central, east, and southern African coun- ported the program for 28 years, and the number of tries not covered by OCP. Controlling the disease was bilateral and multilateral donors increased three-fold technically and organizationally more complex, because over that period. aerial spraying—the only control option available at the time—was considered neither technically feasible nor Striking Success in West Africa cost-effective given the area’s longer distances and thick forests.5 The OCP’s success in controlling onchocerciasis in west Africa has been remarkable. At the start of the program An important scientific breakthrough brought new in 1974, nearly 2.5 million of the program area’s 30 hope to these 70 million people at risk in the region. In million inhabitants were infected, and approximately Angola, Burundi, Cameroon, Central African Republic, Chad, Demo- Benin, Burkina Faso, Côte d’Ivoire, Ghana, Guinea, Guinea-Bissau, cratic Republic of the Congo, Republic of Congo, Equatorial Guinea, Mali, Niger, Senegal, Sierra Leone, and Togo. Ethiopia, Gabon, Kenya, Liberia, Malawi, Mozambique, Nigeria, Later determined to be 14–15 years. Rwanda, Sudan, Tanzania, and Uganda.

Controlling Onchocerciasis (River Blindness) in Sub-Saharan Africa 3 1978, Dr. William Campbell, a veterinary researcher at program, and one of the largest public-private partner- Merck & Co., Inc., discovered that the new antiparasitic ships ever created.7 agent he had developed to treat gastrointestinal worms in cattle and horses was also effective against the family Dr. Foege explained that the program’s goal was to of worms responsible for onchocerciasis. Clinical trials “reach as many people with Mectizan as possible, and to in Africa sponsored by Merck and the WHO dem- make the rules reasonable but not too difficult” (per- onstrated that just one dose of Mectizan (ivermectin) sonal communication, June 2004). The Mectizan Expert could relieve the disabling symptoms of river blindness Committee—a group of experts in tropical medicine, and kill up to 95 percent of the tiny worms—offspring epidemiology, and public health—was established to of the adult worm—for up to a full year.7 Dr. Kenneth lay the rules for how the drug would have to be deliv- Brown, one of the developers of the drug, explained the ered and who would receive it. The committee set up significance of this new one-dose medicine: “Most drugs an annual application process through which requests for the treatment of tropical diseases have to be given in for the drug would be granted based on the applicant’s multiple doses over days, weeks, even years. The ability capacity to distribute the product for at least three years. to treat and control an important disease, such as river The ministries of health had to endorse the applica- blindness, with a single dose each year is nothing short tions, which were submitted mostly by international of spectacular.” nongovernmental organizations (NGOs), medical mis- sion groups, foundations, and the ministries of health Getting the Drugs to Africa: Merck themselves.8 Donates Mectizan On the ground, the task of reaching millions of residents The battle against river blindness now had a powerful of remote villages in east, central, and southern African new weapon in its arsenal. The great challenge facing countries with the drug was daunting. Public health sys- Merck and the public health community, however, was tems were either weak or nonexistent in these countries, to make sure that those most in need of the drug—and health workers were in short supply, and combating also the least able to pay—could access this critical med- onchocerciasis was not seen as a public health priority. icine. Even at a discounted price of $1.50 per treatment, it was clear that the drug would be out of reach to the Two important factors aided the NGO effort: more than developing countries where onchocerciasis was endem- $30 million in grants from the River Blindness Founda- ic. Moreover, resources from the donor community were tion,9 and the popularity that Mectizan acquired because unable to cover the additional cost for the drug, which of its effectiveness in combating many troublesome would have more than doubled program costs. parasites, including intestinal worms, head lice, and scabies, as well as O. vovulus. The drug rapidly alleviates Merck was eager to donate Mectizan, but the company’s incessant itching and is nearly 100 percent effective in initial attempts to find a partner organization to manage treating round worms and whipworms, so improvement the drug’s distribution were unsuccessful. After neither in quality of life is observable almost immediately after the WHO nor the US Agency for International Devel- the first dose. So, despite the fact that the drug must be opment accepted Merck’s offer, the company turned to taken annually for nearly 20 years to interrupt transmis- Dr. William Foege, then executive director at the Carter sion of the disease, Mectizan proved popular and uptake Center. Foege, a veteran of the smallpox eradication across endemic villages was fast. effort, agreed to lead the donation program at the Task Force for Child Survival and Development, an affiliate of The Mectizan Donation Program far exceeded its initial Emory University, only when Merck pledged that its do- goal of 6 million treatments in six years. Since 1988, the nation would be long term. In 1987, Ray Vagelos, then program has provided more than 472 million annual CEO of Merck, made the historic announcement that treatments.10 Merck recommitted to indefinite dona- his company would donate Mectizan “to anyone who tion of the drug, and in 1998 extended its pledge to also needed it, for as long as it was needed”—marking the treat lymphatic filariasis (also known as elephantiasis). launch of the world’s longest ongoing medical donation Transmission of lymphatic filariasis, which WHO has

4 Controlling Onchocerciasis (River Blindness) in Sub-Saharan Africa designated as the fourth largest cause of long-term APOC involved the participation of a wide range of disability in the world, can be successfully interrupted organizations and groups, many of which were also with Mectizan from Merck and albendazole, donated by involved in the OCP, including the same 4 sponsoring Smith-Kline Beecham. agencies, the governments of 19 developing countries, 21 bilateral and multilateral donors, more than 30 par- Two important economic factors have helped to rein- ticipating NGOs, Merck, and more than 100,000 rural force Merck’s decision to make its contribution, which African communities. The primary role of the program is estimated to have a value of over US$1.5 billion: US was to build the capacity of local communities support- tax benefits that reduce the net cost of the program; and ed by the NGOs and the ministries of health to deliver successful marketing of the drug in the veterinary field, Mectizan and to increase the efficiency and sustainabil- which have offset the upfront research and development ity of drug treatment at the local level. costs.11 In 1984, Mectizan was the highest selling animal product and ranked as Merck’s second-best selling drug Unlike the OCP, which involved very limited local par- in 1987.12 The donation program, made more feasible by ticipation, APOC was not a vertical program but rather these economic offsets, represents an important mile- was integrated within the national health systems of the stone in the global effort to eliminate onchocerciasis and participating African countries.5 Ultimate ownership helped pave the way for later donations from multina- for controlling the disease would be the responsibility of tional pharmaceutical companies. the affected communities themselves. The fundamental strategy would be based on community empowerment Reaching the 19 Remaining Countries: with training, oversight, and supervision provided by APOC Is Launched the local health services and collaborating NGOs.

By 1995, however, onchocerciasis still persisted in 19 This donor-funded program is scheduled to end shortly endemic countries not covered by the OCP. To meet after 2010. Effectively interrupting transmission of the the scale of the problem there, it was clear that more disease requires annual drug treatment for some 15 resources were needed to support the efforts of the to 20 years after outside donor funding ceases. Hence, organizations working on the ground, and that a more APOC has placed a strong emphasis on long-term cost-effective, affordable, and sustainable approach than sustainability. the clinic-based Mectizan delivery was necessary.13 To achieve the program’s goal of developing a self- Building on the work of the NGOs in central and east sustainable, fully African-owned and managed program Africa, a new program was launched in 1995 with the in the post-2010 period, APOC has pioneered a system goal of “eliminating onchocerciasis as a disease of public of Community-Directed Treatment with Mectizan health and socio-economic importance throughout (ComDT). Through this framework, many hundreds of Africa.” The African Programme for Onchocerciasis thousands of communities effectively organize and man- Control (APOC) was designed as a 15-year partnership age the local Mectizan treatment, taking full responsi- under the leadership of the World Bank, WHO, UNDP, bility for developing and implementing the strategy for and FAO, which would build on the success of the OCP comprehensive drug distribution and thus enhancing and extend its reach to the remaining 19 endemic coun- prospects for long-term sustainability of the program tries in Africa. The program aimed to treat 86 million after donor funding ends.14 The communities select the people a year by 2010, eventually scaling up to about 90 community-directed distributor, and the distribution million treatments annually; to prevent 54,000 cases of efforts are adapted to the local culture and conditions. blindness per year; to protect the OCP area from reinva- Community volunteers receive training and supervision sion; and to make an estimated 7.5 million additional from the national public health systems and from the years of productive adult labor available for the region’s program’s NGO partners. developing countries.6 The ComDT system has demonstrated its value not only as a cost-effective intervention but also as a successful

Controlling Onchocerciasis (River Blindness) in Sub-Saharan Africa 5 framework for delivering treatment with high coverage The Cost rates to remote populations. In 2000, the WHO estimated that the ComDT network achieved an average treatment APOC bears a total price tag of $180 million. Donor coverage rate of 74 percent, exceeding the minimum 65 funding accounts for 75 percent of this figure, and Afri- percent rate necessary to eventually interrupt transmis- can governments and NGOs contribute the remaining sion and thereby eliminate the disease as a major public 25 percent.5 Merck’s donation of Mectizan and its cover- health problem throughout Africa.1 A further indicator of age of shipping costs of the drug have kept the program’s the strong prospects for the program’s long-term sustain- cost below US$0.60 per person treated per year. Because ability is the increasing rates of coverage in subsequent the World Bank and the WHO waive all administrative rounds of treatment, a trend that illustrates the popularity fees, 100 percent of donor funds reach country opera- of the drug and the success of both the education cam- tions with minimal overhead costs. paigns and the locally run distribution systems.5 A preliminary analysis prepared by the World Bank APOC’s Success in Central, Southern, demonstrated that the economic rate of return for the and East Africa program is 17 percent for 1996 through 2017.17 This rate is comparable to World Bank projects in the most Approximately 41 million people were treated in the 19 productive sectors, such as industry, transportation, and APOC countries with Mectizan by APOC in 2005 alone. agriculture. The WHO estimates that the program prevents approximately 54,000 cases of blindness each year. As it extends Lessons Learned from the Control of its coverage, the benefits will spread over a wider popu- Onchocerciasis Throughout Africa lation and encompass a number of additional positive impacts. These include an 80 percent reduction in the Bruce Benton, manager of the Onchocerciasis Coor- incidence of optic nerve disease, a 50 percent reduction dination Unit in the World Bank from 1985 to 2005, in severe itching, and a 45 percent reduction in visual attributes the success of the programs to a number of deterioration for those with atrophied optic nerves.13 By factors that he believes provide lessons for other disease the time the program begins to phase out at the end of control programs. the decade, it is expected that the sight of more than 800 million individuals will have been saved in the 19 APOC A Comprehensive Regional Approach countries alone.15 Given the natural history of the disease, characterized by the movement of blackfly vectors across national Furthermore, the impact of the successful ComDT borders, a comprehensive regional approach has been system extends beyond the treatment and prevention of essential. The participating African countries were river blindness. The system offers a valuable entry point prepared to contribute to the achievement of a common for other community-directed health interventions in objective provided all would benefit and the burden neglected communities with little or no access to tradi- would be shared relatively equitably. Frequent multi- tional health services.14 In the Central African Republic, country deliberations have exerted peer pressure on the for example, ComDT has provided a stimulus for expand- countries and their professional staff to deliver results. ed primary health care, where the coordinators of the The comprehensive approach employed, and the well- Mectizan distribution program are often the only health defined exit strategies, have helped reassure the donors workers to reach every village.16 Suggestions for health that the efforts would come to a successful conclusion. interventions that could utilize the ComDT framework include long-lasting vitamin A capsules to save lives of Effective Long-Term Partnership children under five by 25–35 percent, improve maternal Regional collaboration among partners was based upon health and prevent deaths; the antibiotic azythromycin, comparative advantage, combined with grassroots com- donated by Pfizer to prevent trachoma; albendazole and munity empowerment, and have proven to be highly ef- Mectizan to halt transmission of lymphatic filariasis; and fective models. The transparent delineation of partners’ praziquantel to cure schistosomiasis. roles in a memorandum of agreement has maximized

6 Controlling Onchocerciasis (River Blindness) in Sub-Saharan Africa effectiveness, minimized turf battles, and helped instill and other diseases such as HIV/AIDS, malaria, cerebral trust among partners. To maintain the partners’ com- spinal meningitis, and possibly avian influenza. mitment and sustain the large coalition over a long period of time, communication has been active and credit Operational Research has been shared liberally. An important contributing factor to the successful control of the highly unpredictable biological agent was the Community Participation and Grassroots program’s emphasis on operational research. Funding Empowerment for operational research was substantial, always exceed- ComDT, a unique feature of APOC, has been integral ing 10 percent of the annual budgets. This research to the program’s goal of eliminating river blindness as proved critical to sustaining OCP in 1985, when the a public health problem throughout Africa. ComDT blackfly vector became resistant to the principal in- has given ownership of Mectizan distribution to the secticide used by the program since 1974. Fortunately, communities where the disease is endemic. The com- the program had developed seven backup insecticides, munities decide their strategies for ensuring the highest which it began to use in rotation until the resistance to compliance with Mectizan treatment and select distribu- the original chemical was overcome after several years, tors in which they have highest confidence. This system marking the first time that any program completely has proven extremely cost-effective, given the donated reversed resistance. drugs and the practice of compensating community distributors with food or other nonmonetary means. Operational research was also vital in determining Both ownership and cost-effectiveness have increased whether ComDT would be cost-effective and achieve the likelihood that the Mectizan treatment network the program’s objectives. The Tropical Disease Research will be sustainable over the long term—a prerequisite (TDR) Program of WHO conducted extensive social for eventual elimination of the disease. Furthermore, surveys in the affected communities and concluded the system of community distributors has addressed that ComDT would be cost-effective and reach a high the paucity of trained health staff in the remote, rural enough portion of the population to eliminate oncho- areas where onchocerciasis is most burdensome. Finally cerciasis over time. It also determined that a much high- ComDT provides a platform for controlling other dis- er proportion of women community distributors would eases, particularly those for which free drug treatment have to be recruited and trained if all members of the or other simple solutions can be “piggy-backed” onto community were to be reached. Finally, TDR developed the Mectizan distribution network. a system of rapid mapping of hyperendemic villages that allowed APOC to map the disease throughout Africa in Capacity Building and Africanization less than 10 years. As a result, APOC operations could The OCP and APOC programs have made deliberate be scaled up much more rapidly than otherwise would efforts to strengthen African management and technical have been possible. capacity. In the mid-1970s nearly 75 percent of OCP’s roughly 30 professional staff were expatriate. Today 99 Dr. Ebrahim Samba, winner of the 1992 Africa Prize for percent of program staff for both OCP and APOC is his contribution to the control of onchocerciasis, high- African, and every director has been African since the lighted the importance of long-term financial commit- early 1980s. More than 100,000 community distribu- ments as a factor contributing to the programs’ success. tors have been trained and retrained since APOC was “Many programs in Africa last three to five years,” Dr. launched in 1995, and more than 500 former OCP staff Samba explained. Such short-term efforts are a “waste of members have returned to their home countries in west time” because “this is the time one requires to study the Africa, bringing advanced degrees, and the scientific, situation, install, and start. One needs more time to get technical, and logistical capacity required to sustain the going, consolidate, and evaluate.” The donor commit- program’s gains. Some of these staff will work on efforts ments of a minimum of 20 years, most of which lasted to improve one of the notoriously weakest links in Afri- 30 years, combined with the commitment from Merck ca’s health system: surveillance of outbreaks, epidemics, to donate Mectizan indefinitely, are an essential element of the effort’s long-term success.18

Controlling Onchocerciasis (River Blindness) in Sub-Saharan Africa 7 A Health Program with a Development 8. Dull HB, Meredith SEO. The Mectizan donation pro- Outcome gramme—a 10-year report. Ann Trop Med Parasitol. 1998;92(suppl 1):S69–S71. In the final year of its operations in 2002, Robert McNamara described the success of the OCP he helped 9. Drameh PS, Richards FO Jr, Cross C, Etya’ale DE, pioneer: “[OCP] has been an enormously effective pro- Kassalow JS. Ten years of NGDO action against riv- gram: a health program with a development outcome; it er blindness. Trends Parasitol. 2002;18(9):378–380. has empowered rural communities to banish this burden and thrive.” Dr. Ebrahim Samba stated, “It proves 10. Thylefors B. 2005 onchocerciasis achievements. it can be done—effective aid programs deliver lasting 2005 Annual Highlights of the Mectizan Donation results. African member-states contributed in cash and Program. Decatur, Ga: Mectizan Donation Program kind, and donors have been steadfast in their support. Secretariat; 2006. This was achieved through hard work, transparency, and accountability.” 11. Coyne PE, Berk DW. The Mectizan (Ivermectin) Donation Program for River Blindness as a Paradigm References for Pharmaceutical Industry Donation Programs. Washington, DC: World Bank; 2001. 1. Benton B, Bump J, Sékétéli A, Liese B. Partnership and promise: evolution of the African river blindness 12. Eckholm E. River blindness: conquering an ancient campaigns. Ann Trop Med Parasitol. 2002;96(suppl scourge. New York Times Magazine, January 8, 1):S5–S14. 1989:20–29.

2. Uche Amazigo, Director, African Programme for 13. Sékétéli A, Adeoye G, Eyamba A, et al. The achieve- Onchocerciasis Control, personal correspondence, ments and challenges of the African Programme July 14, 2006. for Onchocerciasis Control (APOC). Ann Trop Med Parasitol. 2002;96(suppl 1):S15–S28. 3. Kim A, Tandon A, Hailu A, et al. Health and Labor Productivity: The Economic Impact of Onchocercal 14. Amazigo UV, Brieger WR, Katabarwa M, et al. The Skin Disease (OSD). Washington, DC: World Bank; challenges of community-directed treatment with 1997. Policy Research Working Paper 1836. ivermectin (CDTI) within the African Programme for Onchocerciasis Control (APOC). Ann Trop Med 4. Hopkins DR, Richards F. Visionary campaign: elimi- Parasitol. 2002;96(suppl 1):S41–S58. nating river blindness. In: Bernstein E, ed. Medical and Health Annual. Chicago: Encyclopaedia Britan- 15. Uche Amazigo, Director, African Programme for nica. 1997;8–23. Onchocerciasis Control, personal correspondence, July 14, 2006. 5. African Programme for Onchocerciasis Control. Defeating onchocerciasis in Africa. Available at: 16. Hopkins DA. Mectizan delivery systems and cost http://www1.worldbank.org/operations/licus/ recovery in the Central African Republic. Ann Trop defeatingoncho.pdf. Accessed December 13, 2006. Med Parasitol. 1998;92(suppl 1):S97–S108. 6. OPEC Fund. Onchocerciasis Control Program nears completion. Available at: http://www.opecfund. 17. Benton B. Economic impact of onchocerciasis con- org/publications/ar01/boxes/box5.htm. Accessed trol through the African Programme for Onchocer- December 13, 2006. ciasis Control: an overview. Ann Trop Med Parasitol. 1998;92(suppl 1):S33–S39. 7. Merck & Co Inc. The story of Mectizan. Available at: http://www.merck.com/about/cr/mectizan/. 18. Akande L. Victory over river blindness. Africa Re- Accessed December 13, 2006. covery. 2003;17(1):6.

8 Controlling Onchocerciasis (River Blindness) in Sub-Saharan Africa